Headache attributed to head trauma

Kai-Chen Wang MD (Dr. Wang of Cheng Hsin General Hospital in Taiwan has no relevant financial relationships to disclose.)
Shuu-Jiun Wang MD, editor. (Dr. Wang of the National Yang-Ming University School of Medicine and the Neurological Institute, Taipei Veterans General Hospital received consulting fees from Eli Lilly.)
Originally released November 4, 1993; last updated August 9, 2015; expires August 9, 2018

This article includes discussion of headache attributed to head trauma, headache associated with head trauma, postconcussion syndrome, posttraumatic headache, acute posttraumatic headache, chronic posttraumatic headache, headache resulting from scalp laceration or local trauma, headache secondary to neck injury, and headache secondary to temporomandibular joint syndrome. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations

Overview

Headache is common following head injury. Most individuals recover within days, weeks, or months, but a minority of subjects may suffer from intractable posttraumatic headache despite treatment. Posttraumatic headache remains a subject of controversy concerning its pathophysiology. Litigation and medicolegal problems further complicate this issue. This article attempts to summarize current understanding of posttraumatic headache, including a brief historical review of the disease, the classification and diagnostic criteria, the epidemiology, clinical manifestations, pathophysiology, diagnostic evaluation, and management.

Key points

 

• Posttraumatic headache is common following head or neck trauma.

 

• The International Headache Society defines posttraumatic headache as “acute” if headache develops within the first 7 days after the accident and resolves within the first 3 months and “persistent” if headache lasts longer than 3 months.

 

• Underlying pathophysiological mechanisms associated with the development and maintenance of posttraumatic headache remains uncertain and may include psychogenicity and diffuse axonal injury. Different mechanisms may be involved in posttraumatic headache of civilians and that of combat soldiers.

 

• Therapeutic treatment of posttraumatic headache should be individualized and comply with the treatment options for the underlying or accompanying primary headache disorders it resembles.

Historical note and terminology

Headache following head or neck injuries has been reported for centuries. Although the proposed mechanisms for the generation and maintenance of posttraumatic headache have evolved over the years, the subject is still controversial (Evans 2010).

In his book Posttraumatic Neurosis: From Railway Spine to Whiplash, Trimble traces the arguments that began in the 19th century (Trimble 1981). In 1882, Erichsen published a series of lectures concerning how mild head injuries or “spinal concussion” (so-called “railway brain” or “railway spine”) could result in severe disability (Erichsen 1882). However, others casted doubt on the validity of “railway spine” incidence (Rigler 1879). The prevailing view in the 1800s was that headache and other sequelae of head injury were due to malingering or psychogenic or other functional disorders. Interestingly, these contradictory observations were made prior to the development and implementation of worker's compensation and other liability laws (Trimble 1981). One hundred years later, in the chapter on posttraumatic headache in the Handbook of Clinical Neurology, Miller concluded that the posttraumatic syndrome was caused by compensation neurosis or psychoneurosis (Miller 1968). In contrast, Symonds took an opposing position in the article “Concussion and its sequelae” (Symonds 1962).

In 1988, the International Headache Society Classification Committee provided the first formal definitions of acute and chronic posttraumatic headache (Headache Classification Committee of the International Headache Society 1988). In 2004, the revised International Headache Society Classification of Headache Disorders (ICHD-II) categorized “headache attributed to head and/or neck trauma” into 12 subtypes (Headache Classification Committee of the International Headache Society 2004).

In 2013, the International Classification of Headache Disorders, 3rd edition (beta version) (ICHD-3 beta) categorized “headache attributed to head and/or neck trauma” into 8 subtypes:

 

• Acute headache attributed to moderate or severe traumatic injury to the head (ICHD-3 beta code 5.1.1, Table 1 and Table 2)

 

• Acute headache attributed to mild traumatic injury to the head (ICHD-3 beta code 5.1.2, Table 1 and Table 3)

 

• Persistent headache attributed to moderate or severe traumatic injury to the head (ICHD-3 beta code 5.2.1, Table 4 and Table 5)

 

• Persistent headache attributed to mild traumatic injury to the head (ICHD-3 beta code 5.2.2, Table 4 and Table 6)

 

• Acute headache attributed to whiplash (ICHD-3 beta code 5.3, Table 7)

 

• Persistent headache attributed to whiplash (ICHD-3 beta code 5.4, Table 8)

 

• Acute headache attributed to craniotomy (ICHD-3 beta code 5.5, Table 9)

 

• Persistent headache attributed to craniotomy (ICHD-3 beta code 5.6, Table 10)

Table 1. Acute Headache Attributed to Traumatic Injury to the Head

Diagnostic criteria:

(A) Any headache fulfilling criteria C and D
(B) Traumatic injury to the head has occurred
(C) Headache is reported to have developed within 7 days after 1 of the following:

 

1. The injury to the head
2. Regaining of consciousness following the injury to the head
3. Discontinuation of medication(s) that impair ability to sense or report headache following the injury to the head

(D) Either of the following:

 

1. Headache has resolved within 3 months after the injury to the head
2. Headache has not yet resolved but 3 months have not yet passed since the injury to the head

(E) Not better accounted for by another ICHD-3 diagnosis

Table 2. Acute Headache Attributed to Moderate or Severe Traumatic Injury to the Head

Diagnostic criteria:

(A) Headache fulfilling criteria for Table 1 (5.1) Acute headache attributed to traumatic injury to the head
(B) Injury to the head associated with at least 1 of the following:

 

1. Loss of consciousness for more than 30 minutes
2. Glasgow Coma Scale (GCS) score of less than 13
3. Posttraumatic amnesia lasting more than 24 hours
4. Alteration in level of awareness for more than 24 hours
5. Imaging evidence of a traumatic head injury such as intracranial hemorrhage and/or brain contusion

Table 3. Acute Posttraumatic Headache Attributed to Mild Traumatic Injury to the Head

Diagnostic criteria:

(A) Headache fulfilling criteria for Table 1 (5.1) Acute headache attributed to traumatic injury to the head

(B) Injury to the head fulfilling both of the following:

 

1. Associated with none of the following:

 

(a) Loss of consciousness for more than 30 minutes
(b) Glasgow Coma Scale (GCS) score of less than 13
(c) Posttraumatic amnesia lasting more than 24 hours
(d) Altered level of awareness for more than 24 hours
(e) Imaging evidence of a traumatic head injury such as intracranial hemorrhage and/or brain contusion

 

2. Associated, immediately following the head injury, with 1 or more of the following symptoms and/or signs:

 

(a) Transient confusion, disorientation, or impaired consciousness
(b) Loss of memory for events immediately before or after the head injury
(c) Two or more other symptoms suggestive of mild traumatic brain injury: nausea, vomiting, visual disturbances, dizziness and/or vertigo, impaired memory and/or concentration

Table 4. Persistent Headache Attributed to Traumatic Injury to the Head

Diagnostic criteria:

(A) Any headache fulfilling criteria C and D
(B) Traumatic injury to the head has occurred
(C) Headache is reported to have developed within 7 days after 1 of the following:

 

1. The injury to the head
2. Regaining of consciousness following the injury to the head
3. Discontinuation of medication(s) that impair ability to sense or report headache following the injury to the head

(D) Headache persists for more than 3 months after the injury to the head
(E) Not better accounted for by another ICHD-3 diagnosis

Table 5. Persistent Headache Attributed to Moderate or Severe Traumatic Injury to the Head

Diagnostic criteria:

(A) Headache fulfilling criteria for Table 4 (5.2) Persistent headache attributed to traumatic injury to the head
(B) Injury to the head associated with at least 1 of the following:

 

1. Loss of consciousness for more than 30 minutes
2. Glasgow Coma Scale (GCS) score of less than 13
3. Posttraumatic amnesia lasting more than 24 hours
4. Alteration in level of awareness for more than 24 hours
5. Imaging evidence of a traumatic head injury such as intracranial hemorrhage and/or brain contusion

Table 6. Persistent Headache Attributed to Mild Traumatic Injury to the Head

Diagnostic criteria:

(A) Headache fulfilling criteria for Table 4 (5.2) Persistent headache attributed to traumatic injury to the head
(B) Head injury fulfilling both of the following:

 

1. Associated with none of the following:

 

(a) Loss of consciousness for more than 30 minutes
(b) Glasgow Coma Scale (GCS) score of less than 13
(c) Posttraumatic amnesia lasting more than 24 hours
(d) Altered level of awareness for more than 24 hours
(e) Imaging evidence of a traumatic head injury such as intracranial hemorrhage and/or brain contusion

 

2. Associated, immediately following the head injury, with 1 or more of the following symptoms and/or signs:

 

(a) Transient confusion, disorientation, or impaired consciousness
(b) Loss of memory for events immediately before or after the head injury
(c) Two or more other symptoms suggestive of mild traumatic brain injury: nausea, vomiting, visual disturbances, dizziness and/or vertigo, impaired memory and/or concentration

Table 7. Acute Headache Attributed to Whiplash

Diagnostic criteria:

(A) Any headache fulfilling criteria C and D
(B) Whiplash, associated at the time with neck pain and/or headache, has occurred
(C) Headache has developed within 7 days after the whiplash
(D) Either of the following:

 

1. Headache has resolved within 3 months after the whiplash
2. Headache has not yet resolved but 3 months have not yet passed since the whiplash

(E) Not better accounted for by another ICHD-3 diagnosis

Table 8. Persistent Headache Attributed to Whiplash

Diagnostic criteria:

(A) Any headache fulfilling criteria C and D
(B) Whiplash, associated at the time with neck pain and/or headache, has occurred
(C) Headache has developed within 7 days after the whiplash
(D) Headache persists for more than 3 months after the whiplash
(E) Not better accounted for by another ICHD-3 diagnosis

Table 9. Acute Headache Attributed to Craniotomy

Diagnostic criteria:

(A) Any headache fulfilling criteria C and D
(B) Surgical craniotomy has been performed
(C) Headache is reported to have developed within 7 days after 1 of the following:

 

1. The craniotomy
2. Regaining of consciousness following the craniotomy
3. Discontinuation of medication(s) that impair ability to sense or report headache following the craniotomy

(D) Either of the following:

 

1. Headache has resolved within 3 months after the craniotomy
2. Headache has not yet resolved but 3 months have not yet passed since the craniotomy

(E) Not better accounted for by another ICHD-3 diagnosis

Table 10. Persistent Headache Attributed to Craniotomy

Diagnostic criteria:

(A) Any headache fulfilling criteria C and D
(B) Surgical craniotomy has been performed
(C) Headache is reported to have developed within 7 days after 1 of the following:

 

1. The craniotomy
2. Regaining of consciousness following the craniotomy
3. Discontinuation of medication(s) that impair ability to sense or report headache following the craniotomy

(D) Headache persists for more than 3 months after the craniotomy
(E) Not better accounted for by another ICHD-3 diagnosis

Posttraumatic headache research has been hindered by methodological problems, most particularly the heterogeneity of patient populations. Studies may include individuals with both trivial and significant head injuries as well as patients with definite abnormalities on testing and subjects with normal investigations. Furthermore, patients with symptom onset hours after injury have been included with those whose symptoms began months after injury. The ICHD-II provided the operational diagnostic criteria for posttraumatic headache. However, the temporal criterion of the acute and the chronic forms is artificial. Some experts disagreed that onset of headache should occur within 7 days from the injury (or after regaining consciousness) (Young and Packard 1997). The ICHD-3 suggests that there is not enough evidence at this time to change this requirement. It is the hope of the International Headache Society that clinicians and researchers alike will field-test the new diagnostic criteria in both epidemiological and clinical trials.

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